Michael A. Matthay, MD
Program Director
Tel: 415-353-1206
Email: Michael.Matthay@ucsf.edu

PROGRAM MANAGER
Michelle Teng
Tel: 415-502-7434
Email: Michelle.Teng@ucsf.edu

RESEARCH COORDINATORS
Brian Daniel, RRT
Pager:  (415) 719-1370
Email: danielb@anesthesia.ucsf.edu

Rich Kallet, RRT
Pager (415) 719-6219
Email: rkallet@sfghsom.ucsf.edu  

PROGRAM OFFICE ADDRESS
513 Parnassus Ave, HSW 841A
San Francisco, CA 94143-0130
Tel: 415-502-7434
Fax: 415-502-7431

 PROGRAM OBJECTIVE

The Overall objective of the UCSF SCCOR Program in Acute Lung Injury (ALI) is to investigate the pathogenesis and treatment of acute lung injury in humans.  Although considerable progress has been made in selected areas of research and treatment of ALI, the pathogenesis of clinical lung injury is incompletely understood, and mortality remains too high.  Clinical and basic research is needed to provide new knowledge regarding fundamental mechanisms of lung injury as well as to test new therapies for ALI, an important cause of acute respiratory failure in critically ill patients.

MAJOR HYPOTHESES

The following hypotheses provide an overall framework for the University of California, San Francisco SCCOR in Acute Lung Injury.

 First, we hypothesize that Activated Protein C will restore the normal anticoagulant balance in clinical acute lung injury (Project 1). 

Second, we plan to investigate the interactions among human genetics, bacterial genetics and host defense in the development of ALI; the hypothesis that bacterial pneumonia candidate genes may have a high prevalence and a substantial likelihood of being associated with lung injury from infection (Project 2). 

Third, we hypothesize that IL-1b released within the distal airspaces of the lung is responsible for the anb6 integrin-mediated activation of TGF-b1 in lung epithelial cells (Project 4). 

 This program brings together a cohesive group of three projects, an Administrative Core, Clinical Core, and Proteomics Core to support the objectives of each of the three projects.

The major scientific goal of this project is to determine a novel therapy to treat the underlying pathogenesis of acute lung injury (ALI).  Several studies support the hypothesis that the pathogenesis of early lung injury in clinical ALI depends on interactions between coagulation and inflammation in the lung. Activated protein C (APC) is a very promising new therapy that has both anticoagulant and anti-inflammatory properties.  APC is effective in animal models of sepsis as well as in the treatment of some patients with severe sepsis.  There are several important similarities in the pathogenesis of sepsis-induced organ failure and lung injury in ALI, including evidence for coagulation and inflammation dependent injury.  Because our preliminary data indicates that protein C deficiency occurs in patients with either an infectious or noninfectious clinical risk factor for ALI, administration of APC for the treatment of ALI needs to be tested in a broad spectrum of patients who develop ALI. 

The primary hypothesis of this proposed randomized clinical trial is that APC will restore the normal anticoagulant balance in clinical ALI and will reserve a significant fraction of the inflammation-dependent lung injury.  

Aim 1:     Conduct a randomized placebo controlled, double-blind phase II trial to test the potential therapeutic value of APC for the treatment of clinical ALI.  

Aim 2:     Determine the effect of APC (versus placebo) treatment on biologic markers will correlate with improved physiological and clinical outcomes measured in Aim 1.  Aim 2 will also study the effect of APC versus placebo treatment on cell-specific indices of activation and injury to the endothelium, fibroblasts, and the alveolar epithelium. A proteomics analysis will analyze for differences in the protein composition of air space samples in placebo versus APC treated patients.  

PERFORMANCE SITES   

• University of California, San Francisco, San Francisco, CA
• *San Francisco General Hospital, San Francisco, CA
• *University of California, San Francisco, Fresno, Fresno, CA
• Yale University, New Haven, CT
• Stanford University, Stanford, CA

*One of the research and teaching institutions within the University of California, San Francisco system.

KEY PERSONNEL. 

Name

Organization

Role on Project

Matthay, Michael, MD.

UCSF

Principal Investigator

Luce, John, MD.

UCSF

Co-Principal Investigator

Peterson, Michael, MD.

UCSF Fresno

Co-Principal Investigator

Siegel, Mark, MD.

Yale University

Co-Principal Investigator

Weinacker, Ann, MD.

Stanford University

Co-Principal Investigator

The overall objective of this project is to investigate the interactions among human genetics, bacterial genetics and host defense in the development of Acute Lung Injury (ALI) from bacterial pneumonia.  Pneumonia, either as a primary process or as a source of sepsis, is the most important clinical risk factor associated with the development of clinical ALI. 

 Although several genetic abnormalities may predispose to ALI from pneumonia, we propose to take a targeted approach to test a candidate gene that has a high prevalence and a substantial likelihood of being associated with lung injury from infection.  One promising candidate is deficiency of Mannose Binding Lectin (MBL), an immunodeficiency that is common in the general population.  MBL variant alleles have been associated with invasive Pneumococcus, and other bacterial, viral, and fungal lung infections, including P. aeruginosa infections in cystic fibrosis patients.  We will test the hypothesis that genetic abnormalities in Mannose Binding Lectin (point mutations and/or polymorphisms) will increase the frequency and severity of infection-related ALI (aim 1).  Because considerable progress has been made in identifying the molecular mechanisms responsible for the in vivo virulence of P. aeruginosa, the most important cause of Gram negative nosocomial pneumonia, we will prospectively test the impact  of specific Pseudomonas virulence genes on the risk of developing ventilator associated pneumonia among intubated, critically ill patients who are colonized with P.aeruginosa (aim 2).  Finally, in order to evaluate the in vivo virulence of the P.aeruginosa strains cultured from colonized patients and those patients with VAP, we will take advantage of our well established murine models of pneumonia and lung injury.  We will instill Pseudomonas aeruginosa strains from patients with colonization or VAP and test for their virulence in mice by using short and longer term studies to study their effects on alveolar epithelial barrier permeability and lung fluid balance (aim 3).     

Aim 1: Establish a prospective cohort investigation of the role of decreased Mannose Binding Lectin (MBL) concentrations due to genetic abnormalities in the severity of lung infections in critically-ill patients. 

Aim 2: Establish a prospective cohort investigation of the molecular characteristics of P. aeruginosa strains and the genetic expression of virulence genes in colonized and infected patients by obtaining tracheal aspirates and bronchoalveolar lavage from intubated, mechanically ventilated patients. 

Aim 3: Compare P.aeruginosa strains obtained from patients with ventilator associated pneumonia (VAP) and/or ALI to P.aeruginosa strains obtained from ventilated patients who are colonized (without pneumonia) for their capacity to induce lung injury in mice.  

PERFORMANCE SITES 

• University of California, San Francisco, San Francisco, CA

KEY PERSONNEL. 

Name

Organization

Role on Project

Wiener-Kronish, Jeanine, MD

UCSF

Principal Investigator

Gropper, Michael, MD

UCSF

Co-investigator

Dolganov, Gregory, MD

UCSF

Co-investigator

The cytokine transforming growth factor β₁ (TGF-  β₁ ) plays a critical role in the resolution of ALI and in the development of lung fibrosis often associated with this syndrome.  We previously reported that the expression levels of several TGF-β₁–inducible genes are dramatically increased early after the induction of experimental ALI induced with bleomycin.  We also found the anb6 integrin-mediated local activation of TGF-b1is critical to the development of pulmonary edema in ALI and that the activation of TGF-β₁ depends on a change in the conformation of the anb6 integrin.  IL-1b was found to be biologically active and primarily responsibly for the inflammatory activity within the airspaces of patients with ALI.  Finally, preliminary experiments from our laboratory indicate that IL-1b, but not TNF-a, causes activation of the anb6-mediated TGF-b1 dependent cell signaling pathway in alveolar epithelial cells. Thus, this application will test the below hypotheses.  

Aim 1: To determine the mechanisms responsible for the anb6 integrin-mediated activation of TGF-b1 in ALI, the experiments proposed in aim 1 will test the hypothesis that IL-1b released within the distal airspaces of the lung is responsible for the anb6 integrin-mediated activation of TGF-b1 in lung epithelial cells.

Aim 2: To determine the molecular link between the IL-1b-dependent signaling pathway and the anb6 integrin-mediated activation of TGF-b1, the experiments proposed in aim 2 will test the hypothesis that the activation of the focal adhesion kinase (FAK) and/or its downstream cell effectors, phosphoinositol-3-kinase (PI3kinase) and the small GTPases, Rac-1 and RhoA, is required for IL-1b-induced anb6 integrin-mediated activation of TGF-b1 in lung epithelial cells.

Aim 3: To identify the mechanisms for the TGF-b1-induced alteration of the vectorial lung epithelial fluid transport in ALI, the experiments proposed in aim 3 will test the hypothesis that locally activated TGF-b1 decreases basal and c-AMP regulated fluid transport by altering the expression of the amiloride-sensitive sodium channel, ENaC, on the cell membrane of lung epithelial cells.  

 PERFORMANCE SITES 

• San Francisco General Hospital, San Francisco, CA

KEY PERSONNEL. 

Name

Organization

Role on Project

Pittet, Jean Francois, MD

UCSF

Principal Investigator

Matthay, Michael, MD

UCSF

Co- Investigator

Sheppard, Dean, MD

UCSF

Collaborating Investigator

Howard, Mary Beth, PhD

UCSF

Participating Investigator

Kawakatsu, Hisaaki, PhD

UCSF

Participating Investigator

 The Administrative Core provides support to ensure the proper functioning and coordination of the SCCOR. The Core is lead by Michael A. Matthay, MD., who is Principal Investigator of this Acute Lung Injury SCCOR and is responsible for the overall administration of the SCCOR. 

 The Administrative Core provides an administrative assistant for Dr. Matthay to help in coordinating the administration of this large SCCOR program.  The Core also provides a financial analyst to assist in the management of the budget and other financial matters.  This core has responsibility for overall administrative matters for the three projects as well as Cores B and C. This Core has been active in coordinating the monthly meetings to facilitate communication and interaction among the investigators involved in all three projects.  

PERFORMANCE SITES 

• University of California, San Francisco, San Francisco, CA

KEY PERSONNEL. 

Name

Organization

Role on Project

Matthay, Michael, MD

UCSF

Core A leader

The Clinical Core will provide support for the two clinical projects, Project 1 (Matthay) and Project 2 (Wiener-Kronish).  This core will be a Clinical Coordinating Center staffed to support the clinical studies.  This clinical core will provide the organization, personnel and supplies for the screening and enrollment of eligible studies in the adult and pediatric intensive care units at Moffitt-Long Hospital and San Francisco General Hospital.  The clinical core will also provide the support for acquisition and entry of patient data and patient specimens, data analysis, and monitoring of all aspects of the clinical studies to conform to Good Clinical Practice and NHLBI, FDA and UCSF IRB guidelines.  This core will also provide statistical analysis of the data and the support to modify database collections as needed.

PERFORMANCE SITES 

• University of California, San Francisco, San Francisco, CA

KEY PERSONNEL. 

Name

Organization

Role on Project

Wiener-Kronish, Jeanine, MD

UCSF

Core B Leader

Kohn, Michael, MD, MPH

UCSF

Database support

Shiboski, Steven, MD

UCSF

Statistician

The Proteomics Core will study biological samples from all three projects, Project 1 (Matthay) and Project 2 (Wiener-Kronish) and Project 4 (Pittet).   

From the experience gained on the investigation of the lung proteome, analytical limitations of the cleavable isotope coded affinity tag (ICAT) strategy was established for detection and measurement of quantitative changes in protein levels in complex mixtures. The limitations of this strategy include the requirement that a systeine residue be present in the peptide sequence in order to be labeled, affinity purified, and then detected as a ratio of the light and heavy 13C containing analogs.  Thurs, some 8-10 percent of human proteins does not contain even a single systeine residue and thus would not be detected. This technology requires having the ability to measure the quantitative ratios based on precursor ion signals for the light and heavy-isotope bearing peptide. The peptide is identified by sequential, individual selection of each pair and carrying out tandem mass spectrometry sequence analysis for each of these components.  To this end, we implemented software to establish the capacity to carry out the processing required for these cICAT studies.  

In addition, a second stage of chromatography was required to simplify the protein mixtures prior to carrying out RP-HPLC ESI CIDMS.  By design, the quantization information that must be extracted and measured accurately using this reagent resides in the immonium ion region of the fragmentation spectra as distinct from the precursor spectra for cICAT.  

Hence, we have devoted a major successful effort to development of software algorithms that have the capability and capacity to process the large numbers of capillary HPLC electrospray MSMS analyses of > 100 SCX fractions for both identification of the proteins present and measure their relative abundances using 4-plex comparative states made possible by the new iTRAQ isobaric peptide N-terminal labeling reagent.  

This new capability will allow the core to carry out measurements on alveolar type II cells from Project 4 and measure expression changes arising from extracellular cues that reflect changes in cell physiology and/or phenotype in Projects 1 and 2.

PERFORMANCE SITES 

• University of California, San Francisco, San Francisco, CA

KEY PERSONNEL. 

Name

Organization

Role on Project

Burlingame, Al, MD

Core C Leader